Head Trauma

Types of Resulting Brain Injury Primary – occurs at time of impact • Direct neuronal damage, axonal shear → diffuse oedema • Cerebral contusion – diffuse, most often ant/inf parts of frontal/temporal lobes • Intracerebral haematoma – localised, 35% extend into ventricles • Traumatic subarachnoid haemorrhage Secondary – haematoma (EDH, SDH), oedema, ischaemia, hypoxia. May be preventable. Direct – under impact site. Contrecoup – opposite side of brain to impact site. Epidemiology • Common • Male & extremes of age more at risk • MVA, falls & assaults are most common causes. • Alcohol involved in up to 65% of adult head injuries. Assessment Generally if GCS≤13 or GCS<15 in patient>65y then activate Trauma Team, and CT will be ≤ needed. Other (minor) HI will use one or often a combination of NOC, CCHR or NEXUS II head CT rules (see below) to decide on risk & need for CT after initially stratifying with GCS.

History:
In addition to an AMPLE history, the most useful points for risk assessment of significant brain injury in apparently mild HI are: • Dangerous mechanism (fall>5 stairs, MVA with ejection, pedestrian struck) • Focal blow to the temporal/parietal region of the head especially with a heavy implement • Severe persistent headache • Vomiting >2 episodes • Seizure associated with head injury • Post traumatic amnesia > 30 minutes • Ongoing confusion or restlessness • Age > 65 years especially if on aspirin, clopidogrel or other antiplatelet agents • Patient on warfarin or has bleeding disorder (e.g. haemophilia, hepatic failure) Also check: • Drug or EtOH intoxication, pregnancy, known brain pathology or VP shunt

Examination:
For risk assessment of significant brain injury: • GCS score <15 at 2 hours post injury time or any decrease in GCS while in ED • Focal neurological signs, including blown pupil or papilloedema • Suspected open or depressed skull fracture – boggy scalp haematoma • Any sign of basal skull fracture (CSF leak, Battle’s sign, racoon eyes) Also look at: • Vital signs: HT, bradycardia → raised ICP • Related injuries – C-spine and face and other

. UEC. trop/CK. or prophylactic anti-epileptics for late seizures. Mild HI Notes 2% deteriorate NB: Latest Cochrane reviews found no evidence for benefit of hypothermia. FBC. Maintain C-Spine precautions If signs of herniation: mannitol 1g/kg IV over 20min Other supportive care: • Keep T & BSL normal • Correct coagulopathy – FFP 4u & Vitamin K 5-10mg IV • Seizure prophylaxis: phenytoin 1g IV over 20min • ?ABx for open skull # but not CSF leak: cephalothin 2g IV Moderate HI Notes 10% deteriorate. Trauma XRs ± CT C-spine Management Severe HI Notes Intubate within 10mins. traumatic brain injury Imaging: Brain CT or Skull XR/MRI/USS (see below for comparison). coags.Investigations Bloods: BSL. G&H ECG: ?arrhythmia/MI (trigger of fall). Ideally avoiding ↑ICP Head & C-Spine CT <1h. ST elevation in SAH.

or clear fluid. Mort 30%. bilat Babinski. cross sutures. haemotympanum. brief lucidity 30%. 7% ICH. Anosmia. • Base of skull # . ICH may occur after days. • Intracranial haemorrhage: o Extradural: assoc with skull # + torn dural sinus or meningeal a.?petrous temporal bone # ± VII/VIIIn. May be few signs with chronic subdurals.g. Most common. May be acute (<1d). High morbidity & mortality if acute. o Central transtentorial . Complications • Amnesia: common. leaking from the nose or ear o Unusual breathing patterns If elderly. pinpoint pupils. subacute (1-14d) and chronic (>14d). sudden death • Skull fractures: ~50% will not have significant LOC or any neurological findings. limb weakness o Dizziness. white (acute) to dark (>4w) o Subarachnoid: most common in mod-sev HI. post. raccoon eyes. CT: Crescentic.D/C criteria Normal alertness/cognition/behaviour Clinically improving after observation Normal CT or CT not indicated Reliable person to observe at home Able to return if deteriorates Has & understands printed HI advice – return if: o Increasing drowsiness o Worsening headache o Confusion or strange behaviour o Two or more bouts of vomiting o Focal neurological problem.Bilat pinpoint →fixed midsized pupils.. IIIn. doesn’t cross sutures. flaccid paralysis. o Subdural: sudden accel-decel→tearing of the bridging veins. ABx not req. Late CT (6-8h) more sensitive. posturing) • Cerebral herniation: o Uncus transtentorial – IIIn – fixed dilated pupil. alcoholics) and children <2. White. sudden death o Upwards posterior fossa: conjugate down gaze. late: papilloedema.CSF leak. Battle’s sign. often at the site of resolving contusions • Extracranial haemorrhage: scalp lacerations.?cribriform plate # or from ear via ET. depressed #. VIn. o Aural . ABx prophylaxis controversial. ↑HT. No NGT & don't blow nose. No/brief LOC 50%. ↑Risk: temporal # crossing middle meningeal a.. Low risk of meningitis (but higher than aural leak). may be retrograde and/or anterograde • Raised intracranial pressure (↓LOC. loss of balance or convulsions o Any visual problems such as blurring of vision or double vision o Blood. e. ↑tone o Cerebellotonsillar: Pinpoint pupils. may require surgery. closes spontaneously • Meningitis: following skull # may occur wks to yrs later. atrophic brains (elderly. o Intracerebral: cerebral contusions are common and often assoc with SAH. nasal injuries and injuries to the face and neck can lead to significant blood loss • • • • • • . falls risk. Common in severe HI. May present with meningism & has a sig mortality reduced by nimodipine. on anticoagulants have lower threshold to admit. ABx if open. • CSF leak (test for glucose or double halo drop on filter paper): o Nasal . ↓HR. fossa #. ellipse on CT.

Penetrating injuries e.Temporal – above midpoint of zygomatic arch 2 fingers ant to EAM (75%) 2nd try .Frontal – 4 fingers ant and 4 finger sup to EAM (10%) 3rd try . hyperthermia. but symptoms may persist as a post-concussive syndrome for wks-yrs. Technique: 1st try . DI (5% mod/sev HI).Parietal – 4 fingers post and 4 fingers sup to EAM Then try other side O–5% chance of return to independence Prognosis HI + GCS 3 –mortality >95% (penetrating). poor concentration. seatbelts.g. vertigo and cognitive impairment. 15-20% persistent severe disability. morbidity <7% Coma – 66% aware at 3d become independent. and soft surfaces on playgrounds are effective. Procedures Emergency Burr Holes Indication: Deteriorating neurology with blown pupil and access to neurosurg >2h. Concussion: Amnesia and confusion. Late Cx include DIC. 10% vegetative at 7d become independent Brainstem: init fixed pupils – 5% regain conciousness. post-traumatic stress disorder. and later still: chronic daily headache. CT scan may be normal or haemorrhage to deep structures of brain. 60% (blunt trauma) HI + GCS<8 – mortality 30-40%. Rapid ↑ICP & coma. Primary insult is essentially irreversible. none independent Age: Bad: elderly<adult<child :better Hypotension: Very poor prognosis Prevention • Safer roads.• • • • • • Diffuse axonal injury: shearing at white matter and brainstem. barriers to prevent falls. airbags. Other symptoms include dizziness. . High incidence of infection and mortality Seizures: More common following penetrating injury or children. headaches. gunshot wounds. Cranial nerve injuries usually I-VII: I & II may be permanent. Duration of amnesia is predictive of injury severity. Common in MVA & 'shaken baby syndrome'. gastric ulcer. and gun control legislation. HI + GCS >13 – mortality <1% . Resolution is often rapid. N&V. Rx limited to ↓2º damage. rest usually resolve. • Bicycle and motorcycle helmets.

Specificity 50-69% • Nexus II Head CT Rules (largest derivation study. fall>1m or 5 stairs) • Retrograde (before impact) amnesia >30min Performance: Sensitivity 98-100%. miminal head injury (no LOC. Specificity 13-17% • . amnesia. New Orleans Criteria [NOC] (validated) Aim: Identify risk of significant brain injury on CT in minor HI Included: GCS 15. Rule high risk criteria: • • • • • GCS<15 at 2hr post injury Suspected open or depressed skull # Sign of base of skull # ≥2 episodes of vomiting Age ≥ 65y Rule med risk criteria: Dangerous mechanism (Ped vs MV. <16y.Risk Stratification of Head Injury (i. disorientation Excluded: Acute focal neurological deficit.e. obvious penetrating/depressed skull #. Specificity 24-25% • Canadian CT Head Rules [CCHR] (validated) Aim: Identify risk of significant brain injury on CT in minor HI Included: Init GCS 13-15. age≥3. Significant Brain Injury on CT) Glasgow Coma Score GCS often used to initially stratify HI pats as mild (14-15). returned to ED with same injury. ejection MVA. Minor HI subgroup had GCS 15 Excluded: ? Rule criteria: Evidence of significant skull fracture • Scalp haematoma • Neurological deficit • Age ≥ 65y • Altered level of consciousness • Abnormal behaviour • Coagulopathy • Persistent vomiting Performance: Sensitivity 95-98%. disorientation). LOC. bleeding disorder. amnesia. pregnant. moderate (9-13) or severe (3-8). normal neuro ≥ Excluded: ? Rule criteria: Headache • Age≥60y ≥ • Vomiting • Drug or EtOH intoxication • Short term memory loss • Seizure after injury • Evidence of trauma above the clavicles Performance: Sensitivity 100%. LOC/amnesia. but unvalidated as yet) Aim: Identify risk of significant injury on CT in all HI & minor HI () Included: All with CT for blunt trauma. no clear Hx of trauma. fit prior to ED. PO warfarin.

Sp50%) rules . CT scan is required for: History • • • • • • Witnessed LOC>5 min History of amnesia >5 min Abnormal drowsiness >2 vomits after HI ?NAI Fit w/o Hx of epilepsy Examination • • • • • • GCS<14. LOC ≥ 5s.Comparison of Imaging Modalities CT Scan • Indications: (NB Pregnancy (excluded) & severe headache (not predictive) in CCHR) o GCS<13. • Cons: Expense. → No CT 4) Also Davis-California (Sn91-99%. altered mental status or signs of skull # → CT Med risk (~30% of population. multiple vs isolated findings. magnetism CI (no metal resus equip) Special Groups Alcoholic • • • High risk for Cx – low platelets. contusion & sinus inj • Cons: sensitive<CT for fractures. coagulopathy. vomiting. age<3mo or parental preference Low risk (~55% of population. Sens 96-99% Spec 15-21% 2) CHALICE – Sens 98% Spec 5-87%. severe mechanism or severe headache CT favoured over obs based on MD experience. Sp12-43%) and CATCH (unvalidated Sn98%. ~4% risk): GCS14. more avail than MRI. detects 50% of fractures. SDH & EDH. less avail resource. ~1% risk): If <2yrs: Occipital/temporal haematoma. 1:6000 for 15yo) 1) NEXUS II HCT – Can use as above but w/o age criteria. time req. “tunnel of death” away from resus area. <0. sedation/GA/ETT for some (child. or CCHR/NOC/NEXUS II HCT criteria for GCS>13 o If deteriorating (GCS drop by ≥2) o Also if VP shunt or brain lesion known • CI: Unstable patient. needs CT radiographer. brain atrophy – ↑risk esp sub-dural Intoxication makes GCS difficult to assess Social situation more likely close observation at home less likely More prone to develop cerebral oedema than adults May have subtle signs if fontanelle open – but can use USS to scan in this case Children <2 with ICH – 75% have skull #. non-coop) Skull Xray • Only if CT not available. ED Drs can read. severe mechanism or not acting normally Else If ≥2yrs: LOC. or <15 in infant ?Penetrating/depressed skull inj Tense fontanelle in infant Signs of a basal skull # Positive focal neurology Bruise/swelling/lac>5cm in infant Mechanism • • • High-speed MVA/Ped (>30kmh) Fall of >3m High-speed projectile injury 3) PECARN – Sens 98%. 50% only have features of scalp haematoma Paediatric • • • Head Injury CT Algorithms for Children (1:1500 cancer risk for 1yo. child (radiation & need for GA) • Outcome: abnormal rate much high (~3-4x) than significant injury rate • Cx: Small ↑risk of ALL in child if XR or CT in pregnancy • Pros: Highly spec/sens for neurosurg intervention. Spec 59% High risk (14% of population.05% risk): None of High or Med risk features. may have a role in ?NAI Brain USS • Useful in infants esp neonates if fontanelle open or bony defect • Intraoperative USS useful to position or localize ventricular catheters • Needs skilled operator and interpreter of result Brain MRI • Pros: sensitive>CT for shearing white matter injury. worsening signs/symptoms. cost.

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